result from injury of the anterior talobular ligament and can contribute to anterolateral impingement [7]. Medial Complex and Deltoid Ligaments Isolated medial collateral or deltoid liga- ment injuries (Figs. 1 and 59) are infrequent and are commonly associated with injury to other ligaments or malleolar fractures. The medial collateral ligament complex is fur- ther divided into supercial and deep layers. The deep ligaments have talar attachments and cross one joint, whereas the supercial ligaments have variable attachments and cross two joints. The three components that are most often visualized on MRI include the tibiospring and tibionavicular ligaments in the supercial layer and the posterior tibio- talar ligament of the deep layer [8]. Syndesmosis The syndesmotic ligaments include the anterior inferior tibiobular ligament, the posterior inferior tibiobular ligament, the inferior transverse tibiobular ligament, and the inferior interosseous ligament or mem- brane [9] (Figs. 1 and 1012). A syndesmot- ic ligament injury or high ankle sprain can be isolated or may occur in conjunction with injury of other ligament groups. It may also be associated with Weber B or C ankle frac- tures [912]. We have not included an image of the infe- rior transverse tibiobular ligament because no such ligament injuries were encountered during the period of this study. Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments Kiley D. Perrich 1 Douglas W. Goodwin 1 Paul J. Hecht 2 Yvonne Cheung 1 Perrich KD, Goodwin DW, Hecht PJ, Cheung Y 1 Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756. Address correspondence to Y. Cheung (yvonne.cheung@ hitchcock.org). 2 Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH. CME This article is available for CME credit. See www.arrs.org for more information. Muscul oskel et al I magi ng Pi ctori al Essay AJR 2009; 193:687695 0361803X/09/1933687 American Roentgen Ray Society E very day in the United States, roughly 10,000 people will suf- fer an ankle injury, with most of these being sprains [1]. MRI can depict ligament injuries and has been used to differentiate ligament tears from other causes of ankle pain, such as fracture, osteochon- dral injury, or tendon injury. Appropriate treatment planning for ankle injury requires differentiation between the various types of ligament injury. This article provides an overview of the MRI features of normal and abnormal ligaments of the ankle (Appendix 1). Injured ligaments on MRI may appear disrupted, thickened, heterogeneous, or at- tenuated in signal intensity, and may be ab- normal in contour. Fluid-sensitive sequences are often helpful in detecting injury. Imaging was performed at our institu- tion using our standard protocol (Table 1) on a 1.5-T scanner (Signa Horizon LX, GE Healthcare) with an extremity coil. Images used here were collected from patients re- ferred for ankle MRI for ankle pain or for evaluation of injury from December 29, 2003 through August 10, 2007. Lateral Complex The lateral collateral ligament complex (Figs. 14) is the most commonly injured group of ankle ligaments and is often as- sociated with ligament injury elsewhere in the ankle. The lateral complex, comprising the anterior talobular, calcaneobular, and posterior talobular ligaments, is adequately imaged with routine axial and coronal imag- es [26]. Hyalinization of tissue in the an- Keywords: ankle, ligaments, MRI DOI:10.2214/AJR.08.2286 Received December 21, 2008; accepted after revision February 12, 2009. F O C U S
O N : OBJECTIVE. The objective of our study was to provide a pictorial survey of MR images of ankle ligaments in various conditions from intact to disrupted. CONCLUSION. MR images of ankle ligaments from a sample of patients with ankle pain or injury are presented and reviewed. Perrich et al. MRI of Ankle Ligaments Musculoskeletal Imaging Pictorial Essay D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
688 AJR:193, September 2009 Perrich et al. Spring Calcaneonavicular Ligament Complex The plantar calcaneonavicular ligament is also known as the spring ligament complex (Figs. 1 and 1315). The complex extends from the calcaneus to the tarsal navicular. A brocartilaginous portion of the ligament lies supercial to the talar head. The spring lig- ament consists of three components: the su- peromedial calcaneonavicular ligament, the medioplantar oblique calcaneonavicular liga- ment, and the inferoplantar longitudinal cal- caneonavicular ligament [13, 14]. Of these, the superomedial calcaneonavicular ligament is most often involved in acute traumatic in- jury. Published studies of isolated spring liga- ment injuries are rare [15, 16]. Because of the proximity of the spring ligament to the poste- rior tibial tendon and its integral function in stabilizing the plantar arch, spring ligament injuries are often associated with posterior tibial tendon dysfunction [17]. Summary MRI provides a means of depicting liga- ment injuries and can be used to differenti- ate ligament tears from other causes of ankle pain and injury. In this article we have pro- vided guidelines for the MRI differentiation of the various types of ligament injury. Acknowledgment We thank Daniel Deneen for his assistance in preparing and editing this manuscript. References 1. Holmer P, Sondergaard L, Konradsen L, Nielsen PT, Jorgensen LN. Epidemiology of sprains in the lateral ankle and foot. Foot Ankle Int 1994; 15:7274 2. Erickson SJ, Smith JW, Ruiz ME, et al. MR imag- ing of the lateral collateral ligament of the ankle. AJR 1991; 156:131136 3. Farooki S, Sokoloff RM, Theodorou DJ, et al. Vi- sualization of ankle tendons and ligaments with MR imaging: inuence of passive positioning. Foot Ankle Int 2002; 23:554559 4. Kreitner KF, Ferber A, Grebe P, Runkel M, Berg- er S, Thelen M. Injuries of the lateral collateral ligaments of the ankle: assessment with MR im- aging. Eur Radiol 1999; 9:519524 5. Labovitz JM, Schweitzer ME, Larka UB, Solo- mon MG. Magnetic resonance imaging of ankle ligament injuries correlated with time. J Am Po- diatr Med Assoc 1998; 88:387393 6. Lee SH, Jacobson J, Trudell D, Resnick D. Liga- ments of the ankle: normal anatomy with MR ar- thrography. J Comput Assist Tomogr 1998; 22:807813 7. Robinson P, White LM, Salonen DC, Daniels TR, Ogilvie-Harris D. Anterolateral ankle im- pingement: MR arthrographic assessment of the anterolateral recess. Radiology 2001; 221:186190 8. Mengiardi B, Prrmann CWA, Vienne P, Hodler J, Zanetti M. Medial collateral ligament complex of the ankle: MR appearance in asymptomatic subjects. Radiology 2007; 242:817824 9. Bartonicek J. Anatomy of the tibiobular syndes- mosis and its clinical relevance. Surg Radiol Anat 2003; 25:379386 10. Brown KW, Morrison WB, Schweitzer ME, Parel- lada JA, Nothnagel H. MRI ndings associated with distal tibiobular syndesmosis injury. AJR 2004; 182:131136 11. Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeast- ing RA. Radiographic and CT evaluation of tibio- bular syndesmotic diastasis: a cadaver study. Foot Ankle Int 1997; 18:693698 12. Morris JR, Lee J, Thordarson D, Terk MR, Brust- ein M. Magnetic resonance imaging of acute Maisonneuve fractures. Foot Ankle Int 1996; 17:259263 13. Mengiardi B, Zanetti M, Schottle PB, et al. Spring ligament complex: MR imaginganatomic corre- lation and ndings in asymptomatic subjects. Ra- diology 2005; 237:242249 14. Taniguchi A, Tanaka Y, Takakura Y, Kadono K, Maeda M, Yamamoto H. Anatomy of the spring ligament. J Bone Joint Surg Am 2003; 85-A:2174 2178 15. Chen JP, Allen AM. MR diagnosis of traumatic tear of the spring ligament in a pole vaulter. Skel- etal Radiol 1997; 26:310312 16. Pathria MN, Rosenstein A, Bjorkengren AG, Ger- shuni D, Resnick D. Isolated dislocation of the tarsal navicular: a case report. Foot Ankle 1988; 9:146149 17. Anderson MW, Kaplan PA, Dussault RG, Hurwitz S. Association of posterior tibial tendon abnor- malities with abnormal signal intensity in the si- nus tarsi on MR imaging. Skeletal Radiol 2000; 29:514519 TABLE 1: Routine MRI Protocol to Evaluate for Ligament Injury Sequence Plane Frequency- Selective Fat Saturation TR TE Inversion Time (ms) Section Thickness / Interval (mm) Echo Train Length Matrix Spin-echo T1-weighted Sagittal No 400700 1020 4 / 1 256 256 STIR Sagittal No 4,000 50 150 4 / 1 256 256 Fast spin-echo proton densityweighted Oblique axial a Varies 2,0003,000 15 34 / 1 56 512 512 Fast spin-echo proton densityand T2-weighted Axial Yes 3,5006,000 80 4 / 1 56 256 256 Fast spin-echo proton densityweighted Coronal Yes 2,0003,000 15 34 /1 56 256 256 a 45 degrees between coronal and sagittal planes. D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:193, September 2009 689 MRI of Ankle Ligaments APPENDIX 1: Ankle Ligaments Lateral complex Anterior talobular ligament Posterior talobular ligament Calcaneobular ligament Medial complex (deltoid) Tibionavicular ligament Tibiospring ligament Tibiocalcaneal ligament Anterior tibiotalar ligament Posterior tibiotalar ligament Ankle syndesmosis Anterior inferior tibiobular ligament Posterior inferior tibiobular ligament Inferior transverse ligament Distal interosseous ligament or membrane Spring ligament complex (calcaneonavicular ligament) Superomedial calcaneonavicular ligament Medioplantar oblique calcaneonavicular ligament Inferoplantar longitudinal calcaneonavicular ligament A C Fig. 1Ankle ligaments. (See Appendix 1 for full ligament names.) A, Ligaments visible laterally: anterior talobular (L1), calcaneobular (L2), anterior inferior tibiobular (S) ligaments. B, Ligaments visible posteriorly: interosseous ligament or membrane (S1), posterior inferior tibiobular (S2), inferior transverse tibiobular (S3), posterior talobular (L3), tibiocalcaneal (M4), and posterior tibiotalar (M5) ligaments. C, Ligaments visible medially: anterior tibiotalar (M1), tibionavicular (M2), tibiospring (M3), tibiocalcaneal (M4), posterior tibiotalar (M5), and superomedial calcaneonavicular (Sp1) ligaments. D, Ligaments composing calcaneonavicular and spring ligament complex: superomedial calcaneonavicular (Sp1), medioplantar oblique calcaneonavicular (Sp2), and inferoplantar longitudinal calcaneonavicular (Sp3) ligaments. Tibiospring ligament (M3) belongs to supercial layer of medial complex and is included here to show its insertion to superomedial calcaneonavicular ligament. B D D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
690 AJR:193, September 2009 Perrich et al. A C Fig. 2Lateral complex: anterior talobular ligament. Anterior talobular ligament is weakest of lateral ligaments. It extends from anterolateral malleolar tip to talar neck, stabilizing talus. A, 44-year-old woman with chronic ankle pain. Anterior talobular ligament is well visualized on uid-sensitive sequences such as this axial T2-weighted image. Uninjured ligament is of uniform thickness and low T1 and T2 signal intensity (arrow). B, 17-year-old boy with pain and swelling and history of remote ankle injury. Partial tear of anterior talobular ligament on axial T2-weighted image shows thickened ligament with increased internal signal (arrowhead). C, 17-year-old boy with ankle pain after injury. Complete tear of anterior talobular ligament on axial T2- weighted image shows discontinuous ligament surrounded by extensive uid signal (arrow). D, 19-year-old woman with continued ankle pain after sprain. Axial T2-weighted image shows nodular soft tissue occupying anterolateral gutter (arrow). Torn anterior talobular ligament, seen in more distal image, is not included. B D A Fig. 3Lateral complex: calcaneobular ligament. Calcaneobular ligament lies deep in relation to peroneal tendons and extends from lateral malleolar tip to trochlear eminence, stabilizing subtalar joint. Calcaneobular is often partially imaged in coronal or axial planes; multiple images are often needed to visualize its entire course. A, 31-year-old woman with suspected anterior tibial tendon tear. Oblique axial proton densityweighted image of intact calcaneobular ligament (arrow) shows regular contour and homogeneously low signal. (Fig. 3 continues on next page) D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:193, September 2009 691 MRI of Ankle Ligaments Fig. 3 (continued)Lateral complex: calcaneobular ligament. Calcaneobular ligament lies deep in relation to peroneal tendons and extends from lateral malleolar tip to trochlear eminence, stabilizing subtalar joint. Calcaneobular is often partially imaged in coronal or axial planes; multiple images are often needed to visualize its entire course. B, 24-year-old man with Weber type B fracture of bula. Oblique axial T2-weighted image of partial tear of calcaneobular ligament shows uid signal in ligament and mildly irregular contour (arrowhead). C, 41-year-old woman with ankle trauma. Oblique axial T2-weighted image of complete tear of calcaneobular ligament shows discontinuous ligament with adjacent uid signal (arrow). Ligament at its calcaneal insertion (asterisk) is not disrupted. C B A Fig. 4Lateral complex: posterior talobular ligament. Posterior talobular is least frequently injured of three lateral complex ligaments, extending from posterior talus (lateral tubercle) to bular malleolar fossa. Posterior talobular often appears striated on MRI because of its brofatty composition [7]. A, 37-year-old man with medial ankle pain. Normal posterior talobular ligament (arrow) has linear striations on this axial proton densityweighted image. B, 17-year-old boy with ankle pain after injury. Complete tear of posterior talobular ligament is seen as ligament defect on axial T2-weighted image. Torn ends of discontinuous ligament are surrounded by uid signal (arrow). B Fig. 5Medial complex and deltoid: tibionavicular ligament. Tibionavicular ligament inserts onto navicular and is visible on only 55% of MR images of asymptomatic subjects. Because of its variable visualization, it is unreliable in assessing ligament injury. Coronal T2-weighted image in 73-year-old woman with tarsal tunnel syndrome and foot pain shows intact tibionavicular ligament (arrow). D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
692 AJR:193, September 2009 Perrich et al. A Fig. 6Medial complex and deltoid: tibiospring ligament. Tibiospring ligament connects medial malleolar colliculus to superomedial spring ligament. A, 44-year-old woman with ankle pain. Coronal proton densityweighted image of intact tibiospring ligament shows its attachment to spring ligament (arrow). B, 20-year-old woman with Weber type B fracture. Complete tear of tibiospring ligament on coronal T2-weighted image shows discontinuous, irregular bers (arrow). B Fig. 7Medial complex and deltoid: tibiocalcaneal ligament. Tibiocalcaneal connects medial malleolus to sustentaculum tali (asterisk). This ligament is visualized in 88% of asymptomatic subjects on MR images [13]. Coronal T2-weighted image in 29-year- old man with ankle pain shows complete tear and distal disruption of tibiocalcaneal ligament (arrow). Fig. 8Medial complex and deltoid: anterior tibiotalar ligament. Anterior tibiotalar ligament is thin and of uniformly low signal intensity on proton densityweighted images. It is inconsistently visualized on routine MRI studies. Its absence is not reliable indicator of injury. Coronal proton densityweighted image in 56-year-old woman with ankle and foot pain shows intact anterior tibiotalar ligament (arrow). D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:193, September 2009 693 MRI of Ankle Ligaments A Fig. 9Medial complex and deltoid: posterior tibiotalar ligament. Posterior tibiotalar is thickest of medial ligaments with intervening fat separating its fascicles, often resulting in striated appearance in normal ligament. Fascicular disruption, irregularity, and loss of striation are indicators of injury. A, 49-year-old man with Achilles tendinopathy. Coronal T2-weighted image of intact posterior tibiotalar ligament shows continuous bers and intervening fat between fascicles (arrow). B, 29-year-old man with ankle pain. Coronal T2-weighted image of partial tear of posterior tibiotalar ligament shows irregular contour and disrupted bers with uid signal near its talar attachment (arrow). C, 20-year-old man with persistent ankle pain after eversion injury. Coronal T2-weighted image shows complete disruption of posterior tibiotalar ligament and irregular contour of visible bers, none of which appears attached at its talar insertion (arrowhead). C B A Fig. 10Syndesmosis: anterior inferior tibiobular ligament. Anterior inferior tibiobular ligament extends from anterior tibial tubercle to bular tubercle and is best visualized on axial images. Normal anterior inferior tibiobular ligament may show fascicular appearance, which should not be confused with injury or tear. A, 43-year-old woman with ruptured plantar fascia. Intact anterior inferior tibiobular ligament is low in signal intensity on axial proton densityweighted image (arrow). B, 19-year-old man with right-ankle pain after injury. Axial T2-weighted image of partial tear of anterior inferior tibiobular ligament shows uid signal in thickened, irregular ligament (arrowhead). C, 44-year-old man with high bular fracture. Axial proton densityweighted image of complete tear of anterior inferior tibiobular ligament shows discontinuous ligament (arrow). C B D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
694 AJR:193, September 2009 Perrich et al. A A Fig. 11Syndesmosis: posterior inferior tibiobular ligament. Posterior inferior tibiobular ligament extends from posterior tibial tubercle to posterior bula. Most inferior fascicles (not shown) comprise inferior transverse ligament. A, 17-year-old boy with avascular necrosis and steroid therapy. Intact posterior inferior tibiobular ligament (arrow) is seen on axial proton density weighted image. B, 44-year-old man with high bular fracture. Complete tear of posterior inferior tibiobular ligament on axial T2-weighted image is seen as discontinuous ligament (arrow). Fig. 12Syndesmosis: distal interosseous ligament or membrane. Interosseous ligament is inferiormost portion of interosseous membrane. It connects medial bula to lateral tibia. Its inferior margin lies adjacent to tibiobular recess and is lined with synovium [11]. Recess extends superiorly 5 mm from joint line on MR images of healthy subjects [12]. When uid signal extends more than 12 mm into tibiobular recess, syndesmotic injury should be considered [12]. A, 14-year-old girl with ankle pain. Intact interosseous ligament or membrane is seen on coronal T2-weighted image. Note absence of uid in tibiobular recess (arrows). B, 44-year-old woman with ankle pain. Torn interosseous ligament or membrane is seen on coronal T2-weighted image. Fluid signal extends into tibiotalar recess 13 mm superior to joint line (arrow), indicating high likelihood of interosseous ligament or membrane tear. B B A Fig. 13Spring ligament complex: superomedial calcaneonavicular ligament. Superomedial calcaneonavicular ligament originates from sustentaculum tali of calcaneus and inserts onto superomedial tarsal navicular. It lies deep in relation to posterior tibial tendon (PTT). Supercial surface of superomedial calcaneonavicular ligament is composed of brocartilaginous gliding zone. Of three components of spring ligament complex, superomedial calcaneonavicular ligament is most likely to be injured. PTT dysfunction is often associated with spring ligament injury. A, 69-year-old man with high bular fracture and pain. Coronal T2-weighted image shows intact superomedial calcaneonavicular ligament (straight arrow) and adjacent PTT (curved arrow). Normal tibiospring ligament is also visible (arrowhead). Asterisk indicates brocartilaginous gliding zone. (Fig. 13 continues on next page) D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
H o s p i t a l
I s r a e l i t a
A l b e r t
E i n s t e i n
o n
0 8 / 0 4 / 1 4
f r o m
I P
a d d r e s s
2 0 1 . 5 6 . 7 . 1 7 3 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:193, September 2009 695 MRI of Ankle Ligaments Fig. 13 (continued)Spring ligament complex: superomedial calcaneonavicular ligament. Superomedial calcaneonavicular ligament originates from sustentaculum tali of calcaneus and inserts onto superomedial tarsal navicular. It lies deep in relation to posterior tibial tendon (PTT). Supercial surface of superomedial calcaneonavicular ligament is composed of brocartilaginous gliding zone. Of three components of spring ligament complex, superomedial calcaneonavicular ligament is most likely to be injured. PTT dysfunction is often associated with spring ligament injury. B, 69-year-old man with ankle pain and talar osteochondral injury. Axial T2-weighted image shows normal contour and homogeneously low signal in superomedial calcaneonavicular ligament (arrowhead). C, 50-year-old man with foot and ankle pain. Oblique axial T2-weighted image shows partial tear of superomedial calcaneonavicular ligament (arrow). Abnormally thickened, irregular superomedial calcaneonavicular ligament contains bright uid signal. C B A Fig. 14Spring ligament complex: medioplantar oblique calcaneonavicular ligament. Medioplantar oblique calcaneonavicular ligament extends from medial portion of navicular bone to calcaneal coronoid fossa and is best visualized in axial plane. A, 21-year-old man with chronic foot pain. Normal striated appearance of uninjured medioplantar oblique calcaneonavicular ligament is shown on axial T2-weighted image (arrow). B, 50-year-old man with foot and ankle pain. Complete tear of medioplantar oblique calcaneonavicular ligament is shown on axial T2-weighted image. Note irregular, wavy contour of ligament and interruption at its calcaneal attachment (arrow). Fig. 15Spring ligament complex: inferoplantar longitudinal calcaneonavicular ligament. Inferoplantar calcaneonavicular ligament lies anterior to medioplantar oblique calcaneonavicular ligament, extending from inferior navicular bone to calcaneal coronoid fossa. It is usually thickest of three components of spring ligaments and is seen in 91% of asymptomatic subjects [13]. Sagittal T1-weighted image shows intact inferoplantar longitudinal calcaneonavicular ligament (arrow) in 20-year-old man with ankle pain and suspected osteochondral injury. B F O R Y O U R I N F O R M AT I O N This article is available for CME credit. See www.arrs.org for more information. D o w n l o a d e d